The role of nutrition in non-alcoholic fatty liver disease treatment in obese children.

Non-alcoholic fatty liver disease (NAFLD) is a highly prevalent chronic liver disease that occurs mostly in the context of insulin resistance and obesity. It has rapidly evolved into the most common cause of liver disease among children. The incidence is high in obese children and a greater risk of disease progression is associated with severe obesity, highlighting the role of nutrition. To date, there is no consensus on NAFLD management. This is a narrative review of clinical studies on the potential benefit of nutritional interventions, including lifestyle modifications, vitamins, docosahexaenoic acid, and probiotics in children with NAFLD. The Comité de nutrition de la Société Française de Pédiatrie (CN-SFP) emphasizes the effect of limiting added sugar intake, i.e., fructose or sucrose-containing beverages, and promoting physical activity in the care of NAFLD.

Parenteral nutrition for preterm infants: Issues and strategy.

Due to transient gut immaturity, most very preterm infants receive parenteral nutrition (PN) in the first few weeks of life. Yet providing enough protein and energy to sustain optimal growth in such infants remains a challenge. Extrauterine growth restriction is frequently observed in very preterm infants at the time of discharge from hospital, and has been found to be associated with later impaired neurodevelopment. A few recent randomized trials suggest that intensified PN can improve early growth; whether or not such early PN improves long-term neurological outcome is still unclear. Several other questions regarding what is optimal PN for very preterm infants remain unanswered. Amino acid mixtures designed for infants contain large amounts of branched-chain amino acids and taurine, but there is no consensus on the need for some nonessential amino acids such as glutamine, arginine, and cysteine. Whether excess growth in the first few weeks of life, at a time when very preterm infants receive PN, has an imprinting effect, increasing the risk of metabolic or vascular disease at adulthood continues to be debated. Even though uncertainty remains regarding the long-term effect of early PN, it appears reasonable to propose intensified initial PN. The aim of the current position paper is to review the evidence supporting such a strategy with regards to the early phase of nutrition, which is mainly covered by parenteral nutrition. More randomized trials are, however, needed to further support this type of approach and to demonstrate that this strategy improves short- and long-term outcome.

[Iron in nutrition]. / Fer et nutrition.

Iron deficiency is the main nutritional disease worldwide. The multidisciplinary working group of the French Pediatric Society on iron assessed the following recommendations. Since iron is variably absorbed depending on foods, the group defined absorbed iron requirements instead of dietary iron requirements. Iron-rich foods should be introduced at 4-months of age in some breast-fed infants. Between 7 and 11 month-old, formula-fed infants should drink at least 700ml per day of follow-on formula and partially or totally breast-fed infants should receive oral iron supplementation. Between 1 and 6 year-old, children should drink at least 300ml per day of growing-up milk until they become able to consume 100 to 150 grams per day of meat products. From 7 year-old, consumption of 2 portions per day of meat products is necessary in order to achieve daily iron requirements. Oral iron therapy from either increased iron-rich foods consumption or iron salts preparations is indicated when absorbed iron requirements are not achieved or when ferritin concentration is lower than age-specific limit values.

Vitamin A in pediatrics: An update from the Nutrition Committee of the French Society of Pediatrics.

Vitamin A (retinol) fulfills multiple functions in vision, cell growth and differentiation, embryogenesis, the maintenance of epithelial barriers and immunity. A large number of enzymes, binding proteins and receptors facilitate its intestinal absorption, hepatic storage, secretion, and distribution to target cells. In addition to the preformed retinol of animal origin, some fruits and vegetables are rich in carotenoids with provitamin A precursors such as ß-carotene: 6µg of ß-carotene corresponds to 1µg retinol equivalent (RE). Carotenoids never cause hypervitaminosis A. Determination of liver retinol concentration, the most reliable marker of vitamin A status, cannot be used in practice. Despite its lack of sensitivity and specificity, the concentration of retinol in blood is used to assess vitamin A status. A blood vitamin A concentration below 0.70µmol/L (200µg/L) indicates insufficient intake. Levels above 1.05µmol/L (300µg/L) indicate an adequate vitamin A status. The recommended dietary intake increases from 250µg RE/day between 7 and 36 months of age to 750µg RE/day between 15 and 17 years of age, which is usually adequate in industrialized countries. However, intakes often exceed the recommended intake, or even the upper limit (600µg/day), in some non-breastfed infants. The new European regulation on infant and follow-on formulas (2015) will likely limit this excessive intake. In some developing countries, vitamin A deficiency is one of the main causes of blindness and remains a major public health problem. The impact of vitamin A deficiency on mortality was not confirmed by the most recent studies. Periodic supplementation with high doses of vitamin A is currently questioned and food diversification, fortification or low-dose regular supplementation seem preferable.

[Breastfeeding: health benefits for child and mother]. / Allaitement maternel: les bénéfices pour la santé de l'enfant et de sa mère.

The prevalence of breastfeeding in France is one of the lowest in Europe: 65% of infants born in France in 2010 were breastfed when leaving the maternity ward. Exclusive breastfeeding allows normal growth until at least 6 months of age, and can be prolonged until the age of 2 years or more, provided that complementary feeding is started after 6 months. Breast milk contains hormones, growth factors, cytokines, immunocompetent cells, etc., and has many biological properties. The composition of breast milk is influenced by gestational and postnatal age, as well as by the moment of the feed. Breastfeeding is associated with slightly enhanced performance on tests of cognitive development. Exclusive breastfeeding for at least 3 months is associated with a lower incidence and severity of diarrhoea, otitis media and respiratory infection. Exclusive breastfeeding for at least 4 months is associated with a lower incidence of allergic disease (asthma, atopic dermatitis) during the first 2 to 3 years of life in at-risk infants (infants with at least one first-degree relative presenting with allergy). Breastfeeding is also associated with a lower incidence of obesity during childhood and adolescence, as well as with a lower blood pressure and cholesterolemia in adulthood. However, no beneficial effect of breastfeeding on cardiovascular morbidity and mortality has been shown. Maternal infection with hepatitis B and C virus is not a contraindication to breastfeeding, as opposed to HIV infection and galactosemia. A supplementation with vitamin D and K is necessary in the breastfed infant. Very few medications contraindicate breastfeeding. Premature babies can be breastfed and/or receive mother's milk and/or bank milk, provided they receive energy, protein and mineral supplements. Return to prepregnancy weight is earlier in breastfeeding mothers during the 6 months following delivery. Breastfeeding is also associated with a decreased risk of breast and ovarian cancer in the premenopausal period, and of osteoporosis in the postmenopausal period.

[Malnutrition screening in clinical practice]. / Dépister la dénutrition de l'enfant en pratique courante.

Protein energy malnutrition (PEM) occurs when energy and protein intake do not meet requirements. It has a functional and structural impact and increases both morbidity and mortality of a given disease. The Nutrition Committee of the French Pediatric Society recommends weighing and measuring any child when hospitalized or seen in consultation. The body mass index (BMI) must be calculated and analyzed according to references any time growth kinetics cannot be analyzed. Any child with a BMI below the third centile or -2 standard deviations for age and sex needs to be examined looking for clinical signs of malnutrition and signs orienting toward an etiology and requires having his BMI and height dynamics plotted on a chart. PEM warrants drawing up a nutritional strategy along with the overall care plan. A target weight needs to be determined as well as the quantitative and qualitative nutritional care including its implementation. This plan must be evaluated afterwards in order to adapt the nutritional therapy.

Vitamin D: still a topical matter in children and adolescents. A position paper by the Committee on Nutrition of the French Society of Paediatrics.

The aims of the present position paper by the Committee on Nutrition of the French Society of Paediatrics were to summarize the recently published data on vitamin D in infants, children and adolescents, i.e., on metabolism, physiological effects, and requirements and to make recommendations on supplementation after careful review of the evidence. Scientific evidence indicates that calcium and vitamin D play key roles in bone health. The current evidence, limited to observational studies, however, does not support other benefits for vitamin D. More targeted research should continue, especially interventional studies. In the absence of any underlying risk of vitamin D deficiency, the recommendations are as follows: pregnant women: a single dose of 80,000 to 100,000 IU at the beginning of the 7th month of pregnancy; breastfed infants: 1000 to 1200 IU/day; children less than 18 months of age, receiving milk supplemented with vitamin D: an additional daily dose of 600 to 800 IU; children less than 18 months of age receiving milk not supplemented with vitamin D: daily dose of 1000 to 1200 IU; children from 18 months to 5 years of age: 2 doses of 80,000 to 100,000 IU every winter (November and February). In the presence of an underlying risk of vitamin D deficiency (dark skin; lack of exposure of the skin to ultraviolet B [UVB] radiation from sunshine in summer; skin disease responsible for decreased exposure of the skin to UVB radiation from sunshine in summer; wearing skin-covering clothes in summer; intestinal malabsorption or maldigestion; cholestasis; renal insufficiency; nephrotic syndrome; drugs [rifampicin; antiepileptic treatment: phenobarbital, phenytoin]; obesity; vegan diet), it may be justified to start vitamin D supplementation in winter in children 5 to 10 years of age as well as to maintain supplementation of vitamin D every 3 months all year long in children 1 to 10 years of age and in adolescents. In some pathological conditions, doses of vitamin D can be increased. If necessary, the determination of 25(OH) vitamin D serum concentration will help determine the level of vitamin D supplementation.

Prevention of relapse by mesalazine (Pentasa) in pediatric Crohn's disease: a multicenter, double-blind, randomized, placebo-controlled trial.

AIM: This study aimed to test the efficacy of mesalazine in maintaining remission in pediatric Crohn's disease (CD) following successful flare-up treatment. METHODS: In this double-blind, randomized, placebo-controlled trial, 122 patients received either mesalazine 50mg/kg per day (n=60) or placebo (n=62) for one year. Treatment allocation was stratified according to flare-up treatment (nutrition or medication alone). Recruitment was carried out over two periods, as the first period's results showed a trend favoring mesalazine. Relapse was defined as a Harvey-Bradshaw score more than or equal to 5. Time to relapse was analyzed using the Cox model. RESULTS: The one-year relapse rate was 57% (n=29) and 63% (n=35) in the mesalazine and placebo groups, respectively. We demonstrated a twofold lower relapse risk (P<0.02) in patients taking mesalazine in the medication stratum (first recruitment period), and a twofold higher risk in patients taking mesalazine in the nutrition stratum (second recruitment period), compared with the other groups. None of the children's characteristics, which differed across the two recruitment periods, accounted for the between-period variation in mesalazine efficacy. One serious adverse event was reported in each treatment group. CONCLUSION: Overall, mesalazine does not appear to be an effective maintenance treatment in pediatric CD.

[Folic acid and prevention of neural tube closure defects: the question is not solved yet]. / Prévention par l'acide folique des défauts de fermeture du tube neural: la question n'est toujours pas réglée.

Between 1981 and 1996, several interventional studies proved the efficacy of periconceptional folic acid supplementation in the prevention of neural tube closure defects (NTCD), first in women at risk (with a previous case of NTCD) and also in women of the general population in age to become pregnant. The poor observance of this supplementation led several countries (USA, Canada, Chile...) to decide mandatory folic acid fortification of cereals, which permitted a 30% (USA) to 46% (Canada) reduction in the incidence of NTCD. Moreover, this benefit was accompanied by a diminished incidence of several other malformations and of stroke and coronary accidents in elderly people. However, several papers drew attention to an increased risk of colorectal and breast cancer in relation with high blood folate levels and the use of folic acid supplements. A controlled interventional study showed a higher rate of recurrence of colic adenomas and a higher percentage of advanced adenomas in subjects receiving 1mg/day of folic acid. A recent study demonstrated an abrupt reversal of the downward trend in colorectal cancer 1 year after the beginning of cereal folic acid fortification in the USA and Canada. Two studies also reported impaired cognitive functions in elder persons with defective vitamin B(12) status. Taken in aggregate, these studies question the wisdom of a nationwide, mandatory, folic acid fortification of cereals. As of today, despite their limited preventive efficacy, a safe approach is to keep our current French recommendations and to increase the awareness of all caregivers, so as to improve the observance of these recommendations.

The role of "occult" gastroesophageal reflux in chronic pulmonary disease in children.

It has repeatedly been demonstrated that a correlation exists between gastroesophageal reflux and the presence of various "atypical" complaints, such as recurrent chest pain, apneic attacks in infants, and recurrent or chronic respiratory symptoms. Very recently it has been shown that gastroesophageal reflux is frequently associated with non-controlled asthma in children and that medical treatment for reflux can improve the further course of respiratory disease. The aim of the present study was to investigate a possible cause-relationship between recurrent respiratory symptoms in children and the presence of gastroesophageal reflux disease, and to investigate the value of continuous 24-hour esophageal pH-monitoring in the diagnosis and management of these complaints in 62 children with chronic respiratory disease. Continuous 24-hour pH-monitoring was abnormal in 39/62 patients (62.9%). However, no statistically significant correlation could be detected between the presence of gastroesophageal reflux and various anamnestic parameters (parental smoking, pet in household, sibling with gastroesophageal reflux disease), or concomitant atopy. All children that were found positive for gastroesophageal reflux (n = 39) were started on an antireflux therapy (cisapride 0.2 mg/kg q.i.d.). This treatment resulted in an improvement of the symptoms in 84.6%. We conclude that gastroesophageal reflux is an important (causative) factor in chronic recurrent respiratory disease. This entity is often resistant to "classical" respiratory treatment, but can be treated with an anti-reflux therapy. We, therefore, suggest to perform continuous 24-hour esophageal pH-monitorings as a standard procedure in all patients with recurrent respiratory complaints, independent of the severity of their symptoms.

[Somatostatin in a case of neonatal hyperinsulinism caused by focal adenomatosis of the head of pancreas]. / La somatostatine dans un cas d'hyperinsulinisme néonatal par adénomatose focale de la tête du pancréas.

The use of somatostatin in the treatment of a newborn infant with hyperinsulinism is reported. When administered alone, somatostatin was only able to prevent hypoglycemia for a short period of time, whereas the addition of a constant infusion of glucagon allowed successful control of the patient's hypoglycemia. As hyperinsulinism relapsed after a subtotal pancreatectomy, a trial was carried out with a somatostatin analog, which has an expected longer duration of action. It led to a significant rise in the blood glucose level but failed to prevent safely hypoglycemia even when 4 injections were performed daily.

[Crohn's disease in children and adolescents]. / La maladie de Crohn de l'enfant et de l'adolescent.

93 children and adolescents with Crohn's disease have been studied. Terminal ileum (25.8%) and ileum and colon (61.3%) were the most common sites of involvement as determined by X-ray examination. The mean age at the time of diagnosis was 13.2 years. A familial incidence of chronic inflammatory bowel disease was found in 12 patients (12.9%). The most common symptoms were: abdominal pain, anorexia, lassitude, diarrhea, loss of weight. Weight below the third percentile, pain on abdominal palpation, anal lesions, mouth ulcers and clubbing of the fingers were the most common clinical signs at the time of diagnosis. Growth retardation (below the third percentile) was present in 22 of 79 children (27.8%) with a mean follow-up of 40 months. 16 patients out of 75 had initial rectal biopsies with histologic changes characteristic of Crohn's disease. 27 patients had surgical treatment; six of them experienced a relapse within a mean period of 26.7 months. Lastly, the authors show that continuous elemental enteral alimentation (CEEA) during 3 weeks induces a remission. CEEA on a longer period is specially targetted to the treatment of growth retardation.

[A case of diverticular gastric heterotopy of the small intestine]. / A propos d'un cas d'hétérotopie gastrique diverticulaire de l'intestin grêle.

Report of an observation of a small intestine diverticulum with colic and gastric heterotopy in a seven year old girl. Unrecognized for many years, the lesion was at the origin of a severe digestive hemorrhage for which an urgent operation was necessary. A propos of this new enough case (30 published cases), characteristics of diverticular gastric heterotopy are remembered from diagnostic, nosologic and therapeutic point of view. Their individualization with regard to Meckel's diverticulum and remainders of omphalo-mesenteric canal is emphasized.